The nurse notes a history of a grade III heart murmur in a small ...

[armygirl]

The nurse notes a history of a grade III heart murmur in a small infant. When assessing the heart, the nurse would expect to:
 
  1. hear a quiet but easily heard murmur.
  2. hear a moderately loud murmur without a palpable thrill.
  3. hear a very loud murmur with easily palpable thrill.
  4. listen without a stethoscope and hear a murmur at chest wall.

Question 2

The nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first?
 
  1. A child with a temperature of 101 degrees F
  2. A child who has stridor
  3. A child who has absent Babinski sign
  4. A child who has a pot belly appearance

[honnalora]

Answer to Question 1

Correct Answer: 2
Rationale: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

Answer to Question 2

Correct Answer: 2
Rationale: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal.